“The words, life, death, health, disease, have no objective reality.”

An Introduction to the Study of Experimental Medicine, Claude Bernard 

As a medical student, I’m perpetually absorbing knowledge taught to me—by lecturers, teaching assistants, my “colleagues” (professional speak for classmates), residents, and faculty mentors. We are shown mortality rates for different diseases (subtext: we must stop this), case studies (“Patient presents forlorn and apathetic; you diagnose major depressive disorder and prescribe what first line medication?”), and cartoonish signaling pathways (vague in their simplified form, providing the perfect segue into encouragement for us medical students to conduct research). Mortality rates suggest that one role of a doctor is to prevent death. Case studies suggest doctors are meant to find appropriate medications to eradicate whatever symptoms we deem abnormal. Signaling pathways suggest doctors are also researchers, required to understand both human biology and chemistry. There are also classes that provide examples of doctors as ethicists, social justice-minded advocates, public policy advisors, and mental health experts.

What all of these teachings share is a certainty that there are problems, and that medical students can learn—through lectures, textbooks and research—how to fix them. I’m still not clear why we’re making the attribution of one thing as a problem and another as the solution. And I’m concerned we may be doing harm by misdirecting our attention to the end goal rather than to the journey taken to get there. 

Surgeons offer elective procedures, taking patients into the operating room without medical need. According to Dr. Jon Jureidini, antidepressants are being prescribed at concerning rates, and the same case may be made for drugs for hypertension, diabetes, and heart disease—all conditions that can be effectively treated or reversed with changes in diet, exercise, and other lifestyle factors. Elderly patients in nursing homes are prescribed antipsychotics when they are not medically necessary, and without doctors providing patients and families with the information necessary to make an informed decision prior to initiating therapy.

Each of these cases involves the use of harsh medical treatments, but the causes of their medical problems are multifactorial and may be addressed through other approaches. There are arguments in support of these treatments: patients deserve the right to choose for themselves the procedures they want to undergo; lifestyle modification is often unsuccessful, and when the stakes are high, medication is the safest option; and elderly patients with dementia who aren’t medicated are problematic for nursing home staff and fellow residents. But each of these arguments pivots the mission of medicine, turning doctors into providers of treatments that are easiest and most financially lucrative to provide. Likewise, surgery is an invasive, dangerous undertaking with associated risks; the Hippocratic Oath states first to “do no harm.” Lifestyle modification can be challenging as it requires significant behavior modification, but by not focusing our efforts on helping patients succeed in these modifications, we are giving up on the possibility of successfully treating potential causes of their disease without negative side-effects. Dr. Dean Ornish first demonstrated that reversal of coronary artery disease is possible with extensive lifestyle modification, and he has since applied similar interventions to alter the progression of prostate cancer. Using “chemical restraints” in nursing homes for convenience of staff is illegal by federal law—for good reason.

Medicine: Merely a Scalpel for Hire?

In 1975, Dr. Leon Kass attempted to define the goal of medicine in his essay “Regarding the end of medicine and the pursuit of health.” He begins by stating the importance of having a goal: “without a clear view of its end, medicine is at risk of becoming merely a technician and engineer of the body, a scalpel for hire, selling his services upon demand.” Kass defines the goal as promotion of health and describes how health can be assessed based on an understanding of what an individual’s normal functioning entails. Along these lines, GoogleX recently set out to objectively assess health on an individual basis in order to understand how the progression from health to illness occurs. However, in many instances, medicine has become what Dr. Kass warned against: patients present with symptoms, and doctors offer corresponding treatments meant to eliminate the unwanted—each with their own corresponding array of effects, downplayed as “side effects.” Our goals remain scattered.

The very existence of disease relies upon our conception of specific bodily functions as abnormal and problematic. In the same paper, Dr. Kass cites Peter Sedgwick’s Illness—mental and otherwise, in which he radically states: “Outside the significance that man voluntarily attaches to certain conditions, there are no illnesses or disease in nature… The medical enterprise is from its inception value-loaded; it is not simply an applied biology, but a biology applied in accordance with the dictates of social interest.” From this view, doctors don’t heal the sick—they ascribe symptoms to a medical phenomenon and then offer care that perpetuates social norms regarding what is considered “good” and “bad.”

Indeed, medical treatments differ by culture based on what is considered a diseased state. In The Spirit Catches You and You Fall Down, Anne Fadiman describes the struggles of a Hmong family as they receive medical care in the United States for their daughter, Lia, who has epilepsy. Hmong see epileptics as powerful beings, capable of seeing the unseen, and many epileptics become shamans or spiritual healers. Lia’s family was honored by her diagnosis and didn’t trust the treatments offered by Western doctors. Were they negligent, irresponsible parents?

Patient-Centric Approaches

Most often we subjectively self-diagnose as sick or healthy—attributions that don’t always mesh with doctors’ assessments based on physiology and anatomy. As S. Kay Toombs describes in The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient, doctors and patients have different conceptions of illness. She writes:

“The decisive gap between lived experience and scientific explanation… is at the root of the fundamental distortion of meaning in the physician-patient relationship…. Thus, if therapeutic goals are to be optimally effective—and suffering is to be relieved—attention must be directed to the patient’s perceived lived body disruption rather than being exclusively directed towards the objective pathophysiology of the disease state.”

A doctor’s treatment plan may have a profound impact on the trajectory of a patient’s life—its quality and duration—and fitting the treatment to the patient allows for the improvement of both. As Atul Gawande describes in Being Mortal, palliative care (treating patient’s pain and symptoms, rather than the underlying disease) leads to a higher quality and longer duration of life on average in patients with terminal conditions. He describes the impact of targeting treatments to patient needs by describing how his daughter’s piano teacher had her chemotherapy treatments timed to allow her to continue teaching, something that meant a great deal to her.

Recent articles describing successful, unconventional therapies have continued to challenge traditional definitions of medical conditions and treatments. Children diagnosed with obesity are being successfully treated in innovative programs to increase fruit and vegetable consumption. Elderly patients have improvements in sight and dexterity after spending 5 days living as though they were 12 years younger. These findings push medicine in a new direction, toward a different way of conceiving health. What if we stopped seeing obesity as an epidemic and started seeing it as an opportunity to transform the way children understand and relate to food, an opportunity to connect the medical world with agricultural systems to promote environmental and individual health? What if we stopped judging aging as an inevitable path toward developing a conglomeration of medical problems, and instead instilled a sense of strength and possibility in the minds of older patients, giving them the chance to live full and productive lives? Those, I believe, are perspectives that inspire wellness—and truly great medical practitioners.


Further Reading:


Image credit: Andrew Malone via flickr